Download Femoral Neck Fractures

Femoral Neck Fractures
Carol Lin, MD & Brad Merk, MD
Original Authors:
Brian Boyer, MD; March 2004
Steven A. Olson, MD; March 2006
James C. Krieg, MD; May 2011
Revised: March 2016
Epidemiology
• > 300,000 Hip fractures annually in the US
– Accounts for 30% of all hospitalizations
– Expected to surpass 6 million annually
worldwide by 2050
• Significant morbidity, mortality, expense
– $10-15 billion/year in the US
www.ahrq.gov/data/hcup; Kannus et al, Bone 1996; Dy et al, JBJS 2011
Epidemiology:
Bimodal Distribution
• Elderly
– incidence doubles each decade beyond age 50
– higher in caucasians
– smokers, lower BMI, excessive caffeine & ETOH
• Young
– high energy trauma
Anatomy
• Physeal closure age 16
• Neck-shaft angle
130° ± 7°
• Anteversion
10° ± 7°
• Calcar Femorale
Posteromedial
dense plate of bone
calcar
Images from: Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
Blood Supply
• Lateral epiphysel artery
– terminal branch MFC artery
– predominant blood supply to
weight bearing dome of head
• After fracture, blood
supply depends on
retinacular vessels
Images from: Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
Blood Supply
• Greater fracture displacement = greater risk
of retinacular vessel disruption
• Tamponade effect of blood in intact capsule
– Theoretical risk of AVN with increased
pressure
Diagnosis
• Plain Film
– Consider traction-internal
rotation view if comminuted
• CT scan
– Displacement
– comminution
Diagnosis
• MRI
– For evaluation of occult femoral
neck fracture
• Consider MRI in an elderly
patient who is persistently unable
to weight bear
– 100% sensitive and specific
• May reduce cost by shortening
time to diagnosis
Verbeeten et al, Eur Radiol 2005
8
Classification
• Garden (1961)
– Degree of displacement
– Relates to risk of vascular disruption
– Most commonly applied to geriatric/insuffiency
fractures
Garden Classification
I Valgus impacted or
incomplete
II Complete
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement
Garden Classification
• Poor interobserver reliability
• Modified to:
– Non-displaced
• Garden I (valgus impacted)
• Garden II (non-displaced)
– Displaced
• Garden III and IV
Classification
• Pauwels (1935)
– Fracture orientation
– Relates to biomechanical stability
– More vertical fracture has more shear force
– More commonly applied to younger patients or
higher energy fractures
Pauwels Classification
stable
Less stable
unstable
Images from: Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
Treatment Goals:
Geriatric Patients
• Mobilize
– Weight bearing as tolerated
– Minimize period of bedrest
• Minimize surgical morbidity
– Safest operation
– Decrease chance of reoperation
Treatment Goals:
Young Patients
• Spare femoral head
• Avoid deformity
– Improves union rate
– Optimal functional outcome
• Minimize vascular injury
– Avoid AVN
Treatment Options
• Non-operative
• Limited role
• Usually high operative risk patient
• Valgus impacted fracture
• Elderly need to be WBAT
• Mobilize early
Treatment Options
• Reduction and fixation
– Open or percutaneus
• Arthroplasty
– Hemi or total
Decision Making Variables:
Patient Factors
• Young (active)
– High energy
injuries
• Often multitrauma
– Often High
Pauwels Angle
(shear)
• Elderly
– Lower energy
injury (falls)
– Comorbidities
– Pre-existing hip
disease
Decision Making Variables:
Fracture Characteristics
• Displacement
• Stability
– Pauwels angle
– Comminution, especially posteromedial
Pre-operative Considerations
• Traction not beneficial
–
–
–
–
–
No effect on fracture reduction
No difference in analgesic use
Pressure sore/ skin problems
Increased cost
Traction position decreases capsular volume
• Capsule volume greatest in flexion/external rotation
• Potential detrimental effect on blood flow by
increasing intracapsular pressure
Pre-operative Considerations:
Timing of ORIF in Young
• Surgical Urgency
Images from: Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
Time to Surgery
DIFFERENCE
•
Jain et al, JBJS Am 2002
– < 60 years old, 12 hr
cutoff
– 6/38 (16%) with AVN
in delayed group vs
0/15 in early group
• Duckworth et al, JBJS Br
2011
– > 24 hr to surgery
associated with failure
NO DIFFERENCE
• Swiontkowski et al, JBJS
Am1984, 12 hr cutoff
– 20% AVN in < 8 & > 36 hr
groups
• Haidukewych, JBJS Am 2004
– < 50 years old, 24 hr cutoff
– 20% AVN in both groups
– Displacement and reduction
most important
Capsular Tamponade
• Bonnaire et al, CORR, 1998
–
–
–
–
Prospective Study
Increased pressure at 6 hr; 24 hrs; 2 weeks
Displaced and nondisplaced equal
Pressure increases with extension and internal
rotation
– 75% had increased pressure and hemarthrosis
• No clinical proof of efficacy, but basic
science data compelling
Capsulotomy?
• During open reduction or
percutaneously
– Reduces intracapsular pressure
from fracture hematoma
• Bonnaire et al, CORR 1998
• Harper et al, JBJS Br 1991
• Holmberg et al, CORR 1987
• Increased capsular pressure not
clinically associated with AVN
– Maruenda et al, CORR 1997
• 80% of patients with AVN had low
intracapsular pressure
– Vascular damage at time of injury may
be more important
Pre-operative Considerations:
Geriatric
• Surgical Timing
– Surgical urgency in relatively healthy patients
• decreased mortality, complications, length of stay
– Surgical delay up to 72 hours for medical
stabilization warranted in unhealthy patients
– 2.25 increase in MORTALITY if > 4 day delay
• Most likely related to increased severity of medical
problems
Moran et al, JBJS Am 2005
Pre-operative Considerations:
Geriatric
• Regional vs. General Anesthesia
– Mortality / long term outcome
• No Difference
– Regional
• Lower DVT, PE, pneumonia, resp depression, and
transfusion rates
– Further investigation required for definitive
answer
Treatment Issues:
Young patient
• Open reduction
– Improved accuracy
– Decompresses capsule
• May have greater risk
of infection
• Closed reduction
– Less surgical morbidity
Closed versus Open Reduction
• Upadhyay et al, JBJS Br 2004
– Prospective RCT comparing open versus closed
reduction with cannulated screws
• 102 patients < 50 years old
– No difference in AVN or nonunion
– Posterior comminution, poor reduction, and poor screw
placement associated with nonunion
– > 48 hours to surgery in both groups
– Varying constructs
Closed versus Open Reduction
• Higher rate of deep infection in open reduction group
– 0.5% versus 4%
• No difference in AVN
– 17% in both groups
• No difference in nonunion
– 12% in closed group versus 15% in open group (p = 0.25)
Closed versus Open Reduction
• Closed versus open reduction does not seem to
affect nonunion or AVN rates but data is very
limited
– MUST achieve an appropriate reduction
regardless of either method
30
Closed Reduction
• Flexion, slight
adduction, slight
traction
• Apply traction,
internally rotate to 45
degrees, followed by
full extension, slight
abduction
Open approach
• Smith-Peterson
– Direct access to fracture
– Between TFL and
sartorius
– Second approach needed
for fixation
• Heuter modification
– Skin incision over TFL
to avoid injury to LFCN
– Interval same as SmithPeterson
Open approach
• Watson-Jones
– anterolateral
– Between TFL and
gluteus medius
– Same approach for
fixation
– Best for basicervical
Open Reduction Technique
• Fracture table or flat jackson
– Radiolucent under pelvis
• Use schanz pins, weber clamps, or jungbluth
clamp for reduction
• 3 Screws
–
–
–
–
Fixation Constructs
Holmes, 1993
Swiontkowski, 1986
Swiontkowski, 1987
Springer, 1991
• 4 Screws
– Kauffman, 1999
• Dynamic hip screw
– Holmes, 1993
• Blade plate
– Broos, 1998
Fixation Concepts
• Reduction makes it
stable
– Avoid ANY varus
– Avoid inferior offset
• Malreduction likely
to fail
Fixation Concepts
• Screw position matters
– Booth et al, Orthopedics 1998
• Inferior within 3 mm of cortex
• Posterior within 3 mm of cortex
• Need a screw resting on calcar
– Threads should end at least 5mm
from subchondral bone
– Multiple “ around the world views
to check appropriate depth
– Avoid posterior/superior
• to avoid iatrogenic vascular damage
– Should not start below level of
lesser trochanter
• Avoid stress riser
Fixation Concepts
Lateral
Epiphyseal
Artery
Good
Bad
Anterior
Posterior
-
Good spread
Hugging Calcar and
posterior cortex
Posterior and inferior
screws are most important
-
Clustered together
Nothing on calcar
Fixation Concepts
• Screw position matters
– Inferior within 3 mm
of cortex
– Posterior within 3 mm
of cortex
– Avoid
posterior/superior
• to avoid iatrogenic
vascular damage
Fixation Concepts
• Sliding hip screw
– May help with
comminution
– Basicervical
– Accesory screw for
rotation
Fixation Concepts
• Sliding hip screw
– May help with
comminution
– Basicervical
– Accesory screw for
rotation
• Can use small frag
plate for reduction as
well
Cannulated Screws versus Fixed
Angle Device
• Most RCT included elderly patients
• Retrospective cohort studies
– Liporace et al, JBJS Am 2008
• Fixed angle (mix of devices) versus cannulated
screws (multiple configurations)
– 19% nonunion in screws versus 9% nonunion in
fixed angle. Not statistically significant
– Hoshino et al, OTA 2013 paper 54
• Higher reoperation rate with cannulated screw
(pauwel’s configuration)
Cannulated Screws versus
Sliding Hip Screw
• Gardner et al, J Orthopaedics 2015
– Retrospective review of 3 level 1 trauma
centers
– 40 sliding hip screw, 29 cannulated screws
– Poor reduction highly significant for failure
– Cannulated Screws had higher short term
failure
Outcomes
• Slobogean et al, Injury 2015
– 20% rate of reoperation
• Pollak et al, OTA 2012
– at 1 year, patients with no complications reach
population norm SF-36
– with complication substantially disabled
• Especially malunion
• Fewer than 1/3 of published studies include
functional outcomes and < 5% included validated
HRQoL scoring
44
What about Shortening?
• Healed FNF with shortening associated
with poorer functional outcomes
– 56 patients
• 30% with 1cm neck shortening, 8mm femoral
shortening
• Similar in both nondisplaced and displaced
patients
Outcomes
• Haidukewych et al, JBJS Am 2004
– 10% conversion to THA at 2 years
– 20% at 12 years
– 65% at 14 years
46
YOUNG FNF Summary
• Femoral neck fractures in < 60.
– take physiology and activity into account
• Ideally, fix within 24 hours
• Reduction is likely more important than:
– Capsulotomy
– Type of approach
– Method of fixation
• Follow closely for shortening, AVN and
nonunion
47
Treatment Issues:
Geriatric Patients
• Fixation
– Lower surgical risk
– Higher risk for
reoperation
• Replacement
– Higher surgical risk
(EBL, etc.)
– Fewer reoperations
– Better function
[Lu-yao JBJS 1994]
[Iorio CORR 2001]
Treatment Issues:
Geriatric Patients
• Fixation
– Stable (valgus
impacted) fractures
– Minimally displaced
fractures
• Replacement
– Displaced fractures
– Unstable fractures
– Poor bone quality
[Lu-yao JBJS 1994]
[Iorio CORR 2001]
Arthroplasty Issues:
Hemiarthroplasty versus THA
• Hemi
– More revisions
• 6-18%
– Smaller operation
• Less blood loss
– More stable
• 2-3% dislocation
• Total Hip
– Fewer revisions
• 4%
– Better functional outcome
– More dislocations
• 11% early
• 2.5% recurrent
[Cabanela, Orthop 1999]
[Lu –Yao JBJS 1994]
[Iorio CORR 2001]
Hemiarthroplasty Issues:
Unipolar vs. Bipolar
• Unipolar
– Lower cost
– Simpler
• Bipolar
–
–
–
–
–
Theoretical less wear
More modular
More expensive
Can dissociate
NO PROVEN
ADVANTAGE
Arthroplasty Issues:
Cement?
• Cement (PMMA)
– Improved mobility,
function, walking aids
– Most studies show no
difference in morbidity /
mortality
• Sudden Intra-op cardiac
death risk slightly
increased:
– 1% cemented hemi for fx
vs. 0.015% for elective
arthroplasty
• Non-cemented (Press-fit)
– Pain / Loosening higher
– Intra-op or periop fracture
risk higher
• Particularly in men > 80
years
Arthroplasty Issues:
Surgical Approach
• Posterior
– 60% higher short-term
mortality
– Higher dislocation rate
• Anterior/Anterolateral
– Fewer dislocations
Keating et al OTA 2002
ORIF or Replacement?
• Prospective, randomized study ORIF vs.
cemented bipolar hemi vs. THA
• ambulatory patients > 60 years of age
– 37% fixation failure (AVN/nonunion)
– similar dislocation rate hemi vs. THA (3%)
– ORIF 8X more likely to require revision
surgery than hemi and 5X more likely than
THA
– THA group best functional outcome
GERIATRIC FNF Summary
• MRI to rule out occult fracture in older
patients unable to weight bear
• CRPP for valgus impacted or nondisplaced
fractures
• Arthroplasty if displaced
• Consider THA for active older patients
Special Problems:
Stress Fractures
• Patient population:
– Females 4–10 times more common
• Amenorrhea / eating disorders common
• Femoral BMD average 10% less than control
subjects
– Hormone deficiency
– Recent increase in athletic activity
• Frequency, intensity, or duration
• Distance runners most common
Stress Fractures
• Clinical Presentation
–
–
–
–
–
Activity / weight bearing related
Anterior groin pain
Limited ROM at extremes
± Antalgic gait
Must evaluate back, knee, contralateral hip
Stress Fractures
• Imaging
– Plain Radiographs
• Negative in up to 66%
– Bone Scan
• Sensitivity 93-100%
• Specificity 76-95%
– MRI
• 100% sensitivity / specificity
• Also Differentiates: synovitis, tendon/
muscle injuries, neoplasm, AVN,
transient osteoporosis of hip
Stress Fractures
• Classification
– Compression sided
• Callus / fracture at inferior
aspect femoral neck
– Tension sided
• Callus / fracture at
superior aspect femoral
neck
– Displaced
26 y.o. woman runner
Stress Fractures:
Treatment
• Compression sided
• Fracture line extends < 50% across neck
– “stable”
– Tx: Activity / weight bearing modification
• Fracture line extends >50% across neck
– Potentially unstable with risk for displacement
– Tx: EmergentORIF
• Tension sided - Nondisplaced
• Unstable
– Tx: Expedited ORIF
» Protect weight bearing
» Schedule for fixation asap
• Displaced
– Tx: Urgent ORIF
– Fix within 24 hours
Stress Fractures:
Complications
• Tension sided and Compression sided fx’s
(>50%) treated non-operatively
• Varus malunion
• Displacement
– 30-60% complication rate
• AVN 42%
• Delayed union 9%
• Nonunion 9%
Special Problems:
Nonunion
• 0-5% in Non-displaced fractures
• 9-35% in Displaced fractures
• Increased incidence with
–
–
–
–
Posterior comminution
Initial displacement
Imperfect reduction
Non-compressive fixation
Nonunion
• Clinical presentation
– Groin or buttock pain
– Activity / weight bearing related
– Symptoms
• more severe / occur earlier than
AVN
• Imaging
–
–
–
–
Radiographs: lucent zones
CT: lack of healing
Bone Scan: high uptake
MRI: assess femoral head
viability
Nonunion: Treatment
• Elderly patients
– Arthroplasty
• Results typically not as good as primary elective
arthroplasty
– Girdlestone Resection Arthroplasty
• Limited indications
• deep infection?
Nonunion: Treatment
• Young patients
– Valgus intertrochanteric
osteotomy (Pauwels)
Nonunion: Treatment
• Young patients
– Valgus intertrochanteric
osteotomy (Pauwels)
– Creates compressive forces
Special Problems:
Osteonecrosis (AVN)
• 5-8% Non-displaced fractures
• 20-45% Displaced fractures
• Increased incidence with
–
–
–
–
–
INADEQUATE REDUCTION
Delayed reduction
Initial displacement
associated hip dislocation
?Sliding hip screw / plate devices
Osteonecrosis (AVN)
• Clinical presentation
– Groin / buttock / proximal thigh pain
– May not limit function
– Onset usually later than nonunion
• Imaging
– Plain radiographs: segmental collapse / arthritis
– Bone Scan: “cold” spots
– MRI: diagnostic
Osteonecrosis (AVN)
• Treatment
– Elderly patients
» Only 30-37% patients require reoperation
• Arthroplasty
– Results not as good as primary elective
arthroplasty
• Girdlestone Resection Arthroplasty
– Limited indications
Osteonecrosis (AVN)
• Treatment
– Young Patients
» NO good option exists
• Proximal Femoral Osteotomy
– Less than 50% head collapse
• Arthroplasty
– Significant early failure
• Arthrodesis
– Significant functional limitations
** Prevention is the Key **
Complications
• Failure of Fixation
– Inadequate / unstable reduction
– Poor bone quality
– Poor choice of implant
• Treatment
– Elderly: Arthroplasty
– Young: Repeat ORIF
Valgus-producing osteotomy
Arthroplasty
Complications
• Fracture Distal to Fixation
–
–
–
–
20% screws at or below Lesser Trochanter
Poor bone quality esp. with anterior start site
Poor angle of screw fixation
Multiple passes of drill or guide pin
• Treatment
– Elderly & Young: Repeat ORIF of neck?
Refixation of neck and subtrochanteric fx
Remove posterior screws & bypass with IMN
Femoral Neck Fx, Garden I
CR, Perc Screw Fixation
Watch Screws Below LT Level
(20% Fx Rate)
At 3 wks:
In NH  Fall
Spiral ST Femur
Below FN Fx
Maintain FN Screws
Good Alignment & Start
Ream & Insert Behind FN Screws
@ 3 Months
Healed FN & ST Fx
Ambulating without Aide
Complications
• Post-traumatic arthrosis
• Joint penetration with hardware
• AVN related
• Blood Transfusions
– THR > Hemi > ORIF
– Increased rate of post-op infection
• DVT / PE
– Multiple prophylactic regimens exist
– Low dose subcutaneous heparin not effective
Complications
• One-year mortality 14-50%
• Increased risk:
–
–
–
–
–
Medical comorbidities
Surgical delay > 3 days
Institutionalized / demented patient
Arthroplasty (short term / 3 months)
Posterior approach to hip
Summary
•
•
•
•
Different injury in young and old
Important injury in both young and old
Understand goals of treatment
Maximize outcome with least iatrogenic
risk
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